For this edition of Voices of Patient Safety, we sat down with long-time patient safety advocate Dr. Abraham Jacob, Chief Quality Officer (CQO) of M Health Fairview and Associate Professor in the Department of Pediatrics and Internal Medicine at the University of Minnesota. Dr. Jacob is a Pediatrician, Internal Medicine, Pediatric Hospitalist at M Health Fairview Masonic Children’s Hospital (UMMCH), and a faculty member of the Institute for Healthcare Improvement’s CQO development program, dedicated to impacting the quality of patient care delivery. Drawing on years of primary care experience, inpatient care delivery, and quality improvement work, Dr. Jacob explains how standardizing handoffs can enhance patient outcomes, reduce adverse events, and improve efficiency and add value for healthcare professionals.

Tell us about your professional background.

In 1998, after completing my Internal Medicine/Pediatrics residency at the University of Minnesota, I helped to form the first Internal Medicine/Pediatrics primary care practice in the Twin Cities with five of my residency classmates. As medical director of the practice, I became interested in panel management, looking at how we could improve the clinical quality metrics of our patient population through systems improvement. After seven years of primary care practice, I returned to the University of Minnesota in 2005 to start and build the Pediatric Hospitalist program at UMMCH.

My time starting and building the hospitalist program only deepened my interest in clinical quality, patient safety, and health systems improvement. In 2012, I completed a master’s in healthcare administration at the University of Minnesota, and from 2012 to 2019, I served as Chief Medical Officer of our children's hospital, leading quality and patient safety efforts and implementing a high reliability platform. Since 2019, I have served as Chief Quality Officer at M Health Fairview, a 10-hospital system in Minnesota which includes an academic medical center and our academic children’s hospital at the University of Minnesota.

How did your experience caring for patients fuel your interest in patient safety and experience and quality improvement in healthcare systems?

As stewards of such a significant resource, we need to commit to building better systems. Trillions of dollars are spent on healthcare delivery each year, and yet the quality of what we deliver is less than desired. It's sad for me to think that we contribute to clinician burnout and patient harm because of systems that basically tie the hands of our frontline staff. Everyone who chooses a career in healthcare wants to do right by their patients, but persistent defects in our systems impede the process, replacing that motivation with feelings of moral injury and burnout. As leaders, we must be focused on how we can work together to redesign and improve those systems.

Since joining the M Health Fairview system nearly 20 years ago, how have you seen patient safety and care quality evolve?

We’ve learned a lot about building safer systems, and our understanding of patient safety continues to grow. By delving into the safety science behind human error, we can better educate our teams around risk prevention. For example, do we feel empowered to speak up when something doesn't look or feel right? Are we mindful in high-risk situations like ordering or administering a medication? Are we oriented around asking questions versus assuming everything must be fine? Are we communicating clearly when we're passing information? These are all parts of the safety science that we must continue educating and training our people on.

In terms of evolution, our work is far more complex than it was 20 years ago, which changes how we need to approach harm reduction. While we know certain high risks will always be present, we must push ourselves to mitigate harm wherever possible, if not eliminate preventable harm entirely.

How do family-centered care and communication work together to reduce harm and improve care quality?

Family- and patient-centered care is foundational to healthcare delivery. The mindset should be we can’t do this to patients, we must do this with patients. Making the right treatment plan is important, but the relationship between the patient, their family, and their healthcare providers is just as—if not more—important. If the patient doesn’t have faith in their care team, they’re unlikely to follow our advice and recommendations. To earn a patient’s trust, we need to initiate authentic conversations and communicate transparently. When I talk to medical students and residents about navigating care conversations with patients and building trust, it’s always about improving the outcome.

When did you first hear about I-PASS, and how did you know it was different from other handoff methods and tools?  

In 2014, I read an article in The New England Journal of Medicine showing how standardized handoffs could significantly reduce adverse events. I was very involved in this at my own institution, so finally having that evidence was such a seminal moment for me. Without a structured framework like I-PASS in place, handoffs form one of the largest sources of clinical variation––and risk––in the system. As leaders, we want to build and standardize the expectation of what a handoff looks like and give our staff the tools to make it easier, more efficient, and safer to execute. The I-PASS bundle helps us get back to the fundamentals of patient care delivery, and that's exactly what we need to do.

Prior to implementing I-PASS at M Health Fairview, what were some of the challenges you saw care teams having when it came to communication and handoffs?

An ongoing issue is clinicians assuming they know how to hand off patients because they’ve done it a certain way for their entire careers. But even an error rate as low as 1% can still cause significant harm. In the past, we’ve implemented the I-PASS mnemonic, but that alone didn’t provide our people and teams with the proper tools or system-based framework to actually go back and improve those processes through continuous feedback.

I appreciate that I-PASS provides a true bundle of solutions. It’s especially helpful because it gives our teams a shared mental model of what reliable handoff communication––and the process that surrounds it––looks like for M Health Fairview. It’s all about creating better handoff systems to ensure this vulnerable aspect of the care delivery process is done with both mindfulness and kindness for each other and our patients.

As a champion of patient safety, how do you think the implementation of I-PASS will impact provider workflow, teamwork, and organizational situational awareness across your health system?

We’re developing a common language around who's at-risk on a particular unit, so any charge nurse, supervisor, provider, or resident can walk into any unit and ask who the “watchers” or “unstable” patients are and what they need to be aware of. They can go through our EHR and immediately pull up a standardized list of at-risk patients—that’s going to be tremendously helpful for building situational awareness and proactive surveillance of patients on all of our units. This is what I’m most excited about.

We have also seen a significant benefit with our float teams of nurses and respiratory therapists. They are the most excited about being able to plug into the system and know how we do a handoff and what tools to use when they enter any given unit.

Can you tell us about your system’s mission to achieve zero harm and the Safety Always initiative?

Our goal has always been to eliminate preventable harm for patients and our staff. We’ve improved in many areas, and in some parts of our system, we’ve maintained zero harm for more than a year, which is a remarkable success. However, there are other areas where we continue to fight the battle. We had to reframe how we think about safety from a human factors or systems resilience engineering framework. I-PASS is part of this reframing. When handing off a high-risk patient or very complex case from team to team or person to person, we ensure we’re doing everything we can to prepare that team or that individual for not just what’s happened to this patient or case, but what could happen, so we position each member of the team for success and increase our situational awareness as a system of care delivery.

We started the Safety Always initiative at our children's hospital. As a member of the Children's Hospitals’ Solutions for Patient Safety network, they offered high reliability training and education. As Chief Medical Officer at the time, I became a trainer and began educating all our staff—including nurses, doctors, respiratory therapists, pharmacists, environmental services, and more—about high reliability and safety science. We systematically reviewed each safety event and developed mitigation plans. This led to a reduction in serious safety events, and our adult partners at the University Medical Center adopted the same approach. This was the beginning of our health system’s high reliability journey.

Where is M Health Fairview on the path to becoming a high reliability organization (HRO)?

Compared to where we started we’re doing better, but we still have work to do. Over the past five years, we've done a tremendous amount of work to develop a common language and standardized training. While we haven’t fully reached zero harm, we’re getting better at systems resilience. We continue to learn from events across our entire health system and are hopefully preventing or mitigating against allowing the same event to happen again elsewhere. One of the biggest domains of high reliability is communication, and a frequent, fundamental aspect of communication is handoffs. The I-PASS bundle really complements our high reliability work by standardizing our expectations and providing the tools to make communication easier.

Throughout the process of implementing I-PASS and advancing your HRO journey, have you noticed a shift in M Health’s culture?

Absolutely. Seeing the pride our team members take in providing great care and doing the right thing adds meaning to our calling in healthcare. There's nothing better than knowing you helped to improve the outcome, return patients to function, keep staff safe, and build meaningful relationships across our teams and with patients and their families.

What advice would you give to other aspiring HROs?

One, just because everyone was trained on communication, don’t assume it will always go well. Two, this is not about individuals behaving badly, it's about a flawed system. Three, acknowledge that even though your teams are executing handoffs and communicating well 90% of the time, we must improve the other 10% to reduce the risk of adverse events—and this is where I-PASS makes it easier to do the right thing.

On a personal level, how do adverse outcomes fuel your commitment to patient safety and systems improvement?

When harm does occur, there’s sadness in knowing our systems failed our staff and a patient. Earlier in my career, I remember rounding at a patient’s bedside and watching the nurse double check with myself and a specialist before administering a high-risk medication. Through no fault of their own, they ended up giving this patient the wrong dosage. It led to a safety event, and I felt terrible—we didn’t protect the patient and we couldn’t give our nurse the guidance they needed, even when they asked for help.

These types of errors and subsequent apologies to patients and families really come from the heart and reinforce my commitment to making the system better and safer. I still think about those patients and families a lot as we do this work—I want to be able to tell them that because of them and their stories, we’re constantly striving to build a better and safer system.

Can you tell us about the podcast you host for M Health Fairview?

As host, I see myself as a facilitator, interviewing various subject matter experts and asking inquisitive questions to my colleagues. I aim for authentic conversations that use accessible language. We talk about a range of topics like improving “observed-to-expected mortality” rates, our organ transplant program, surgical site infections, our neonatology program, and any other big changes happening across the health system. Overall, it's been fun to interview leaders and humanize them. I also do a monthly fireside chat with various executives with members of our quality and safety team. We like to end those conversations by asking our guests to pick a walkout song and playing it for them. It catches them off guard, but it keeps the conversation fun.